Making Surgery Safer

William Berry

The task of making surgery safer by decreasing the errors that lead to patient injury and poor results is a considerable undertaking. The surgical system involves thousands of procedures performed in many different settings and requires the skills of multiple different professions and professionals. Compounding that complexity is the sheer volume of procedures, both a justification of the effort and a significant challenge in spreading change to everywhere it is needed. The latest estimate from our own data is that 300 million surgical cases are performed each year, exceeding the number of childbirths and touching patients in every country in the world. With a goal of improving care for every surgical patient in every setting, three principles emerge. First, fixing an entire care system at once is impossible so the effort should be aimed at a single point in the care process where there is much to lose and much to gain. For surgical patients that critical moment is the time immediately surrounding the performance of the surgical procedure, a time that is filled with risk and linked closely to the patient’s outcome. Second, the changes that are considered should favor simple over complex for if simple change is hard, complex is often impossible. And third, there should be potential and possibility for widespread uptake and effectiveness - high impact.

It was with a focus on the critical moment of passage through the operating room, a dedication to simplicity in concept, and the potential for high impact that 10 years ago the WHO surgical safety checklist was born in a process touched by experts from around the globe. Everyone gathered with a common goal of making surgical care safer and more effective for patients. The tool was specifically built to help close gaps in the delivery of surgical care to patients between doing what we know we should do and actually doing it. This is called the “know-do” gap and over the last twenty-five years, considerable evidence has been gathered that shows that this gap – between current knowledge of best practice and what is actually delivered to patients – is substantial and while present across all of healthcare, is certainly present in surgery. The effort produced a checklist, a simple list of things to confirm, to carry the message and do the work. It had to be understandable and not intimidating. In the end, it occupied a single page. We quickly learned that the real magic of the checklist comes through actual use in the operating room with the team referring to the checklist as a memory aid to make certain that needed processes take place and that necessary discussions between team members also happen. It cannot work if it is not used. It is that simple. Don’t read from it and you will forget things and steps will be skipped, sometimes very important ones. Don’t read from it and you will not have important conversations prompted, and again critical information will not be shared. And patients will suffer as a result. The next stage of the work required taking the checklist from an idea, a piece of paper, to actual use at the side of patients in operating rooms globally. That journey started with a pilot test done at eight sites around the world involving nearly 8,000 patients. The pilot demonstrated two important things: first, that the checklist could indeed be used in operating rooms and second, that through its use both complications and mortality could be reduced. That effectiveness when used has been demonstrated many times since.

Challenges in bringing the checklist into widespread surgical practice were anticipated based on prior efforts to improve results after surgery. It was more than a century ago that Ernest Codman left the Massachusetts General Hospital to found the “End Result Hospital” – an institution dedicated to getting the best outcomes after surgical procedures through measuring what really matters to the patient, “the end result.” That measurement he coupled with actively taking what he learned in caring for each patient to improve care for the next. Most surgeons at the time actively resisted the idea of methodically observing and recording outcomes, perhaps fearing that they would be judged against the results of their fellow surgeons or would scare patients away from having a procedure done. But they also likely felt that they, personally, had little room for improvement. Dr. Codman’s experience teaches us a couple of very important lessons – first, in order to improve anything, you have to know where you are starting and “making the invisible visible” through rigorous measurement is absolutely essential, and second, if you are trying to improve surgical care and outcomes for patients, you are likely to encounter skepticism from those you are trying to help improve because they don’t think that they need to or can improve. Checklists themselves can also present unique barriers to use in healthcare, particularly when intended for use by physicians. Even though checklists have been used for decades in industry to improve human performance, they are new to physicians. Further, physicians are the one member of the healthcare team whose work consists of a mixture of science and the art of healing, an effort that we still call the “practice” of medicine. The standardization of the “practice” through the use of tools like checklists has therefore come slowly to physicians who often perceive them as a painful and unnecessary intrusion on physician autonomy – pushing them towards what is called “cookbook” or recipe driven medicine. And while convincing physicians to be leaders in bringing this tool to patients can be difficult, a lack of institutional commitment and scarce resources are also frequently encountered.

If a checklist can only work if it is used and barriers to use are substantial, where do solutions lie? In observing uptake of the checklist by many organizations, some successful and others not, there are a number of steps in the implementation process that we have identified as important. The effort must be a visible priority of organizational leadership and be given the resources needed to do the hard work of implementation. It takes a team to do surgery, and it takes a multidisciplinary team to bring the checklist to life. Multiple perspectives really matter. The checklist must be more than adopted, it must be adapted by the organization to reflect and respect local practice and culture. Failure to adapt will lead to failure to use. Introduction of the checklist should be staged and should start small. Missteps can then be quickly recognized and corrected. Everyone who will be touched by the checklist should have a one on one conversation about it before using it, ideally with practice before use. If they are not spoken with they will lack commitment and not even try. And finally, if we want things like checklists to stick and become a permanent way of safely delivering care, then we need to dedicate ourselves to taking care of it forever. We need to keep an eye on performance and like Dr. Codman did for his patients, and to dedicate ourselves to continually improving the tool that can help every surgical patient get the care that they deserve, every time, everywhere.

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